PHYSICAL EXAMINATION CHAPTER 30 MOD 2 | 139
QUESTIONS AND ANSWERS | WITH COMPLETE
SOLUTIONS!!
chief complaint: Answer - A statement in the patient's own words that
describes the reason for the visit.
holistic: Answer - Considering the patient as a whole; includes the physical,
emotional, social, economic, and spiritual needs of the person.
differential diagnosis Answer - Considers which one of several diseases may be
producing the patient's symptoms. The possible causes for a set of symptoms
are considered in order to arrive at a diagnosis. A differential diagnosis is based
on information gathered from the patient about symptoms; contributing family,
personal, and social histories; and a complete physical examination.
clinical diagnosis Answer - The clinical diagnosis is arrived at after taking a
detailed history and doing a comprehensive physical examination, but before
any laboratory tests or x-rays, diagnostic testing is done.
Collecting the History Information Answer - The documentation should include
the following:
• Purpose of the patient's visit, written as the chief complaint (CC)
• Patient's vital signs (VS)
• Height and weight
,• Pain; documented using a scale of 1 to 10, with 1 being the least amount of
pain and 10 being the greatest amount. In some facilities, the provider takes
the medical history during the patient's initial visit.
Components of the Medical History Answer - Database, Chief complaint (CC),
History of present illness (HPI), Past history (PH) or past medical history (PMH),
Family history (FH), Social history (SH), Systems review (SR) or review of
systems (ROS).
Database Answer - The record of the patient's demographic information along
with history, physical examination, and initial laboratory findings. As new
information is added, it becomes part of this database.
Chief complaint (CC) Answer - The purpose of the patient's visit. Generally, this
is documented in the patient's own words.
History of present illness (HPI) Answer - The medical assistant should gather as
much information about the health problem as possible and document it
concisely in chronologic order.
Describes the signs and symptoms from the time of onset.
Past history (PH) or past medical history (PMH) Answer - A summary of the
patient's previous health. It includes dates and details about the patient:
• Usual childhood diseases (UCD or UCHD)
• Major illnesses
• Surgeries
• Allergies
• Accidents
• Immunization record
, Family history (FH) Answer - Details about the patient's parents and siblings
and their health; if they are deceased, the age and cause of death. This
information is important because certain diseases and disorders have familial
or hereditary tendencies.
Social history (SH) Answer - This section includes information about the
patient's lifestyle:
• Whether he or she feels safe at home
• Use of tobacco, alcohol, or recreational drugs
• Sleeping and exercise habits
• Typical diet
• Education and occupation
• Dental care history
• For female patients, their last menstrual period (LMP), pregnancy history, and
method of birth control if sexually active.
Systems review (SR) or review of systems (ROS) Answer - A systems review is
obtained through a logical sequence of questions about the state of health of
body systems, beginning with the head and proceeding downward. The
provider typically completes this section of the medical history while
conducting the physical examination.
Allergy Documentation Answer - Each medical practice has a policy on how to
document a patient's allergies. In a paper record, they typically are written in
red ink or identified by a colored sticker so that all healthcare workers can
easily see it. EHR systems have methods for including allergy information on all
pertinent screens in the patient's record.
QUESTIONS AND ANSWERS | WITH COMPLETE
SOLUTIONS!!
chief complaint: Answer - A statement in the patient's own words that
describes the reason for the visit.
holistic: Answer - Considering the patient as a whole; includes the physical,
emotional, social, economic, and spiritual needs of the person.
differential diagnosis Answer - Considers which one of several diseases may be
producing the patient's symptoms. The possible causes for a set of symptoms
are considered in order to arrive at a diagnosis. A differential diagnosis is based
on information gathered from the patient about symptoms; contributing family,
personal, and social histories; and a complete physical examination.
clinical diagnosis Answer - The clinical diagnosis is arrived at after taking a
detailed history and doing a comprehensive physical examination, but before
any laboratory tests or x-rays, diagnostic testing is done.
Collecting the History Information Answer - The documentation should include
the following:
• Purpose of the patient's visit, written as the chief complaint (CC)
• Patient's vital signs (VS)
• Height and weight
,• Pain; documented using a scale of 1 to 10, with 1 being the least amount of
pain and 10 being the greatest amount. In some facilities, the provider takes
the medical history during the patient's initial visit.
Components of the Medical History Answer - Database, Chief complaint (CC),
History of present illness (HPI), Past history (PH) or past medical history (PMH),
Family history (FH), Social history (SH), Systems review (SR) or review of
systems (ROS).
Database Answer - The record of the patient's demographic information along
with history, physical examination, and initial laboratory findings. As new
information is added, it becomes part of this database.
Chief complaint (CC) Answer - The purpose of the patient's visit. Generally, this
is documented in the patient's own words.
History of present illness (HPI) Answer - The medical assistant should gather as
much information about the health problem as possible and document it
concisely in chronologic order.
Describes the signs and symptoms from the time of onset.
Past history (PH) or past medical history (PMH) Answer - A summary of the
patient's previous health. It includes dates and details about the patient:
• Usual childhood diseases (UCD or UCHD)
• Major illnesses
• Surgeries
• Allergies
• Accidents
• Immunization record
, Family history (FH) Answer - Details about the patient's parents and siblings
and their health; if they are deceased, the age and cause of death. This
information is important because certain diseases and disorders have familial
or hereditary tendencies.
Social history (SH) Answer - This section includes information about the
patient's lifestyle:
• Whether he or she feels safe at home
• Use of tobacco, alcohol, or recreational drugs
• Sleeping and exercise habits
• Typical diet
• Education and occupation
• Dental care history
• For female patients, their last menstrual period (LMP), pregnancy history, and
method of birth control if sexually active.
Systems review (SR) or review of systems (ROS) Answer - A systems review is
obtained through a logical sequence of questions about the state of health of
body systems, beginning with the head and proceeding downward. The
provider typically completes this section of the medical history while
conducting the physical examination.
Allergy Documentation Answer - Each medical practice has a policy on how to
document a patient's allergies. In a paper record, they typically are written in
red ink or identified by a colored sticker so that all healthcare workers can
easily see it. EHR systems have methods for including allergy information on all
pertinent screens in the patient's record.
